Question

D. D. is a 66 year-old female suffering from shortness of breath. She smoked 2 packs a day until she quit 2 years ago. She has a history of bronchiolitis, hyperinflated lungs, pulmonary edema, and syncope. Her primary care practitioner suspects she also has pulmonary hypertension (PH). After examination, D. D. has a PAP of 35mmHg and mild CHF. Citing scholarly resources, answer the following questions: 1. What is pulmonary hypertension and how could D. D. have developed PH? 2. How does her history fit in with her new diagnosis?

Answer 1

Systolic pulmonary artery pressure lies between 18 to 25 mm of Hg. When the pressure inside systolic pulmonary artery exceeds 25 mm of Hg due to increase in amount of resistance within lungs is termed Pulmonary hypertension.

Two types of pulmonary hypertension & its causes:

• Primary pulmonary hypertension causes are idiopathic, raynaud's phenomenon, liver disease, sickle cell disease, oral contraceptive use,etc.
• Secondary pulmonary hypertension is caused by COPD, smoking, pulmonary emboli, vasculitis, congenital heart diseases, diffuse interstitial pneumonia, left ventricular failure, mitral stenosis, obesity.

The high pulmonary vascular resistance due to increased pressure in pulmonary arteries ,increase the workload of right ventricle . This makes the muscles in the right ventricle thickened and enlarged leading to right ventricular hypertrophy.

• Bronchiolitis is one of the infection in lungs which may destroy small air sacs(alveoli) in lungs .
• Hyperinflated lungs occurs due to loss of elasticity in lungs parenchymal cells. Incomplete emptying of air from airsacs due to loss of elasticity makes air get trapped inside lungs leading to hyperinflation. Smoking is the main risk factor destroying lung parenchymal cells.
• Pulmonary edema is accumulation of fluid in alveoli of lungs . This brings about impaired gas exchange due to decreased function of lungs.
• Syncope occurs when there is lack of oxygen in brain tissues.

The patient was a chronic smoker which was the main risk factor for developing congestive heart failure and increased pulmonary artery hypertension. Dyspnea is a common manifestation for patient having pulmonary hypertension, pulmonary edema, emphysema , CHF.

• Chronic smoking would have destroyed her lung tissues which led to hyperinflation of lungs .
• Due to loss of elasticity of lung cells , the lungs cannot normally carry out the process of purifying blood ( gaseous exchange which removes carbondioxide and saturates blood with oxygen)
• Lungs cannot receive more blood from heart via pulmonary artery , leading to back flow of blood into right ventricle
• The pressure inside pulmonary artery increases , same time the right ventricle struggles to withstand pooling of blood ending up in enlargement of walls (hypertrophy)
• Right ventricle becomes weak due to dilatation and may lead to congestive heart failure if left untreated.
• Due to thickening of cells in right ventricle , the heart cannot pump blood effectively into lungs, so the pressure in the blood vessels increases,due to compensatory mechanisms retain sodium and water is activation of the renin-angiotensin-aldosterone system. The fluid volume increases and symptoms include dependent edema in legs. At resting position the excess fluid starts to redistribute centrally , causing pulmonary edema( fluid is pushed into the air spaces (alveoli) in the lungs).